We carried out the first part of the inspection of Nelson Manor Care Home on 3, 4 and 5 November 2015 and the second part on 9 and 10 December 2015. Our visits on the 3 November and 9 December 2015 were unannounced.
Nelson Manor Care Home is registered to provide personal and nursing care for up to 70 people. There were 52 people accommodated at the time of the first part of the inspection. Accommodation is provided in 70 single bedrooms on three floors. The ground floor provides personal care for older people, the middle floor known as the Jubilee unit provides personal and nursing care for people with mental health needs and the top floor provides people with nursing care. All the bedrooms have an ensuite with a shower facility. The home is located in a residential area approximately one mile from Nelson town centre.
At the time of the inspection the home was being run by a new manager who had started working in the home on 19 October 2015. There was no registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At the last inspection on 10 and 11 February 2015 we found the provider was not meeting a number of regulations in force at the time. We therefore asked the provider to take action to improve the management of medication, make an appropriate response following a safeguarding incident, ensure people were protected from the risks of inadequate nutrition and dehydration, ensure people’s healthcare needs were met in timely manner and improve record keeping. We also recommended the provider seek advice and guidance on improving the level of cleanliness, the implementation of the Mental Capacity Act 2005, the development of person centred care and the development of suitable activities.
Following the inspection, the registered manager sent us an action plan which set out the action they were taking to meet the regulations. However, the registered manager left the home and the action plan was revised and updated by the management team who took over the day to day operation of the service.
During this inspection we identified there were continuing shortfalls in the management of medication. We also found new breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. These were in relation to safe care and treatment, staffing, need for consent, safeguarding people from abuse, person centred care and good governance. You can see what action we have asked the provider to take at the back of the full version of the report.
We also made recommendations about improving people’s experiences at mealtimes, making appropriate adaptations to the environment to support people living with dementia and we have repeated our recommendation to develop suitable and meaningful activities.
People told us they felt safe and were complimentary about the staff team and the management of the service. However, we found improvements needed to be made to the management of medication.
Individual risks had been assessed and recorded in people’s care plans. In order to help staff have an overview of people’s needs and areas of risk we found, on the second part of the inspection, the manager had developed a live communication board. This was continually updated to ensure staff had access to up to date information.
Since our last inspection the provider had increased the level of staffing. Staff working on the ground floor and Jubilee unit told us they had sufficient time to spend with people and carry out their duties. However, we noted the number of staff available on the top floor meant they prioritised completing care duties rather than meeting individual needs. On our visit on 9 and 10 December 2015 we found the manager had deployed an additional member of staff to the top floor on most days.
On our visit on 3, 4 and 5 November 2015, we found new staff had not completed induction training and established staff had not received refresher training in key aspects of their work. We saw no records of staff supervision and appraisal. This meant staff were not adequately supported in carrying out their roles. On our visit on 9 and 10 December 2015, we noted one member of staff had completed a local induction programme and the staff training matrix had been updated. Whilst some training had been booked for early in 2016, there were still significant gaps in the staff training. We also noted the manager had completed supervision with individual members of staff following issues raised about their performance.
We found a large majority of the staff had not completed training on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). This meant they had limited knowledge of the principles associated with the legislation and people’s rights. As a result, appropriate assessments and DoLS applications had not been carried out.
People were served with nutritious food; however, our observations indicated improvements should be made to the way food is served to people. During our inspection on 9 and 10 December 2015, we found the manager had implemented an effective system to record and monitor people’s dietary and fluid intake.
People’s healthcare needs were met and appropriate referrals had been made to specialist services as appropriate.
There were appropriate arrangements in place for the ongoing maintenance and repair of the building. However, there was limited signage and adaptations to support people living with dementia. This meant some people were disorientated within their living environment.
All people had a care plan, which had been reviewed on a monthly basis. However, on the first part of the inspection, three staff spoken with had not read people’s care plans and told us they relied on information shared at handover meetings and in the communication book. This meant the care plans were not used as part of daily practice. On the second part of the inspection, we found staff working on the Jubilee unit were assigned specific people to care for during the day. This meant staff were aware of their responsibilities and this helped to ensure people’s needs were met.
People living on the ground floor had been involved in the care planning process, however, there was no evidence people living on the Jubilee unit had been supported to make or participate in making decisions relating to their care.
There were limited opportunities for people to engage in meaningful activities. There were numerous gaps in the activity records and there was no evidence alternative activities had been offered when people had declined.
People were aware how to make complaints and were confident the manager would listen and take appropriate action. There was an appropriate system in place to ensure complaints were investigated and responded to.
All people, staff and relatives made positive comments about the manager and were optimistic the necessary improvements were being made to the service. The manager had held meetings with staff and relatives and along with the interim governance manager had begun to complete audits to check the quality of the service. Action plans had been devised to address any shortfalls. The manager was supported in her role by the provider and following the inspection we received an internal action plan which set out the resources available to the manager to help her develop and improve the service. However, we found a number of concerns during the inpsections which should have been addressed.